FARMERS MARKET VENDOR LICENSE APPLICATION Dept. of Human Services Public Health Division 2110 Washington Blvd Suite 350 Arlington, VA 22204 Phone (703) 228-7400 Fax (703) 228-7401
2016/17 Receipt # __________Posted
Please provide the information requested below. Return your completed application and processing fee of $40 (checks made payable to Treasurer, Arlington County). Application type:
New
License Renewal
MARKET & VENDOR INFORMATION Owner/Proprietor
Partnership
Corporation
Business Name _______________________________________________________________________ Business Address _____________________________________________________________________ City, State, Zip Code ___________________________________________________________________ Phone Number _______________________________ E-mail __________________________________ Name of Vendor Representative (On-site at the market): (1)___________________________ Phone #___________________________ (2)___________________________ Phone #___________________________ Market Locations ____________________________________ __________________________________ ____________________________________ __________________________________
COOKING WITH PROPANE If you will be cooking with propane (LPG), a permit may be required from the Fire Prevention Office. Please contact them at 703.228.4644 between the hours of 8 am - 4 pm, Monday through Friday.
ON-SITE SET-UP If there will be cooking, reheating, slicing, chopping, cutting, mixing or any other type of food preparation on-site, the following will be required: Hand washing: A 5-gallon container with potable water and a spigot that can be left in the open position to leave hands free for washing, a container to catch wastewater, liquid hand soap, and paper towels Utensil washing: Three 3-gallon containers; one with detergent/water, one with clear water and one with (1TBS/gal.) bleach/water If there is no cooking, reheating, slicing, chopping, cutting, or mixing, chemically treated hand wipes may be used for hand washing.
CONTINUED ON BACK
FOOD INFORMATION (List all food and beverage items that will be sold at the market) FOOD PRODUCT DESCRIPTION
MAIN INGREDIENTS
SOURCE OF PRODUCT/ WHERE IS FOOD PREPARED**
ON-SITE COOKING PROCEDURE (i.e., grill, microwave, oven, etc.)
METHOD OF HOT/COLD HOLDING
**Copy of USDA/Dept. of Agriculture Inspection or a local Health License may be required for the source of the products you are selling at the market. By signing this statement you attest to the accuracy of the information provided in the application and agree to comply with the Food and Food Handling Code, Chapter 9.2, of the Arlington County Code. Applicant’s Signature ______________________________________________________________________ Applicant’s Name/Title (printed)______________________________________________________________ Phone _____________________________ Date ______________________________ Official Use Only Posted:
_________________________________________________________
Healthspace Entered by / Date: ___________________________________________
Revised 1/4/16